ABSTRACT

CORRESPONDING AUTHOR:
Sreenivas Gouripeddi,
Assistant Professor,
Department of ENT,
SVMC/SVRRGGH,
Tirupati-517507, A. P, India.
E-mail: vas_gouripeddi@yahoo.co.in

ABSTRACT: Laryngeal foreign bodies in adults are rare. The foreign bodies accidentally entering the larynx are symptomatic in the form of choking, stridor or even death. We are presenting a rare case of foreign body in the larynx in a 42 year old male who was symptom free except for dysphonia. The foreign body was removed successfully under local anesthesia.

KEYWORDS: Foreign body, Larynx.

INTRODUCTION: Foreign bodies (FB) accidentally entering the larynx are uncommon in adults unless they are inebriated and most of the foreign bodies of larynx present with severe cough or may produce severe respiratory obstruction, sometimes death.^[1] A ‘silent’ (Asymptomatic) foreign body in the larynx is unusual^[2] and must be identified and treated. We present a rare case of foreign body of larynx which was managed successfully.

CASE REPORT: A 42 years old male by name X presented to ENT OPD with a complaint of difficulty to speak following heavy meal which included mutton along with alcohol 3 days back. He consulted a local ENT surgeon and he was diagnosed to have foreign body larynx based on clinical examination which included indirect examination larynx. He was referred to SVRRGGH, Tirupati as it is tertiary care hospital. On examination patient was conscious, unable to speak and indirect examination of larynx showed a thin bone impacted between vocal cords lying antero- posteriorly restricting the vocal cords mobility (Fig. 1). X-ray Neck lateral view showed an ill-defined opacity overlapped by thyroid cartilage. The foreign body was removed by passing a direct laryngoscope under local anesthesia and it was identified as bone measuring 5x3cm size (Fig. 2) and patient was observed for respiratory distress and he was later discharged.

DISCUSSION: Foreign body impaction in the larynx in adults is rare due to well-developed laryngeal protection and thus foreign bodies enter the hypopharynx or passed down the tracheo-bronchial tree. Impaction in larynx is seen only in unconscious patients or those who are inebriated. FB gets lodged at glottis level when it is too large to pass down or when the FB edges are irregular.^[3,4]

Most of the foreign bodies involving the larynx are symptomatic in the form of choking, respiratory distress /stridor and sometimes sudden death and they should be managed immediately.

The management sometimes is preceded by tracheostomy to relieve respiratory obstruction. Asymptomatic nature of the foreign bodies of larynx can be explained when they are present in abnormal position by impaction and when they are large.^[5] Most of the foreign bodies pass down the tracheo-bronchial tree and produce symptoms at a later stage. In our case the foreign body was thin and got impacted antero-posteriorly because of its large size and was asymptomatic (silent) and produced dysphonia because of restriction of movements of vocal cords. In one case wood impaction produced dysphonia as reported by Baumgartner BJ.^[6]

Because of the narrowness of rima glottides FB change the direction antero-posteriorly. In one case reported by Wither, American coin (Dime) was retrieved from vestibule of larynx which presented as hoarseness. When a FB tries to enter the larynx through glottis, spasm and severe cough expels it to supra glottis and if cough is forceful FB expels out of larynx and if cough is weak because of alcohol intoxication it may be held up in the vestibule of the larynx.^[7]

Most of the management consists of tracheostomy followed by foreign body removal using a Bronchoscope under general anesthesia. In some cases FB in larynx can be removed under local anesthesia to prevent slippage of FB particularly smooth FB like coin in one case, an alpin impaction resulting from casual fiddling in the other.^[2] Egg shells, glass fragments, plastic are sometimes impacted because of sharp edges adhering to the laryngeal mucosa.^[8] It is thus emphasized that casual fiddling is avoided with smooth objects to avoid impaction particularly in adults. In our case as the patient was adult and well co-operative foreign body was removed successfully under local anesthesia.

In summary, the asymptomatic nature of the FB, its impaction at the glottis and its removal under local anesthesia without any complications and quick relief to the patient symptoms make it an interesting case record to share with the medical fraternity.

Fig. 1: Indirect laryngoscopy picture showing foreign body lying antero-posteriorly in glottis.

Fig.1

Fig. 2: A thin foreign body (bone) measuring 5x3cm after removal.

Fig.2

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